There Are Two Wolves in Healthcare Technology

If your expertise brought us to this, then of what use was your expertise?

As the late-2010s cringe meme said: inside you, there are two wolves. In healthcare technology, the two wolves are the Expert and the Outsider.

The Expert understands the US healthcare system, the techno-legal-medical nexus that surrounds it, its vested interests and the reasons why things are the way they are.

The Outsider sees the problems and they propose their fix.

I’ve worked in healthcare IT and healthcare technology for 10 years, and I’ve never met a single person in healthcare who doesn’t acknowledge that there are serious problems in the US healthcare system.

Experts are probably more aware of the problems even than the Outsider, but their understanding is complicated by their understanding of the reasons behind the problems; and why solving them is not as simple as ‘doing X thing.’ The Expert is more likely to champion tweaks and feasible changes and less ambitious overhauls.

This post— **Why Are Cancer Guidelines Stuck in PDFs?—**which reached the top of HN this week shows the dichotomy clearly, as does its comment section. The engineer author embodies the Outsider by pointing out something: NCCN cancer guidelines are often available in non-computable PDF files. He created a very cool POC that uses a LLM and very savvy data modeling to make these guidelines interactive and chat-able. You should definitely read his post and check out his prototype! Many HN commenters, embodying the healthcare Expert, pointed out some reasons why NCCN guidelines as PDFs make sense in the current system, and some problems with the idea that a NCCN chat interface would make a huge difference in the current healthcare system. The author engaged very thoughtfully with these responses.

Expert vs Outsider: Cage Match

I’m not totally comfortable calling myself a true expert on healthcare data. The field is too vast and so variegated. There are exceptions and nuances to every rule. Maybe I am just chilling in the low point of the Dunning-Kruger curve.

But, after this time, I can feel the voice of the “Expert” bubble up inside me. I understand some baseline realities that aren’t as obvious to Outsiders, or that at least many such Outsiders overlook. For example, the average amount of time in the typical PCP visit ranging from 15-20 minutes, and there are a huge laundry list of quality-measure and reimbursement-driven items that need to be performed and documented that clinicians have to get through in each one.

This is why it’s not trivial to “just” ask PCPs to do [some additional thing you think may improve outcomes but has no clear path to reimbursement].” I understand intimately why it’s hard to use the data we have collected in EHRs for clinical research. Outsiders who are new to healthcare trumpet their brand new solution to Problem X, I can sometimes feel my jaw start to clench.

It’s easy to see the shortcomings of the Outsider’s approach. Sometimes, they seemingly don’t understand healthcare at all, either from a technology or the experience of being a patient or caregiver. Other times, Outsiders understand these perspectives extraordinarily well, but they may not have a strong grasp of reimbursement or administrative and regulatory requirements, or the historical and contextual reasons that EHRs and other pieces of healthcare technology are the way that they are.

Often, they ignore all of the “experts” telling them why their idea won’t work, or won’t be paid for, or won’t actually solve the problem because there are X, Y, Z other multi-factorial causes of the problem. It can feel as though some Outsiders haven’t considered that many people with good ideas, good intentions, and strong knowledge and capabilities have been working around and with these problems for decades.

If a problem was easy to solve, wouldn’t it have been solved by now? Is new technology so groundbreaking and novel that it can wipe away layers of technical, organizational, financial, legal/regulatory, and psychological context? Do these Outsiders think everyone working in healthcare simply doesn’t work as hard, simply lacks the acumen, or are too compromised by their proximity to the current system to fix easily solvable problems?

When channeling Expert energy, it’s easy to poke holes, to immediately reject, to bristle. I find myself doing it more and more, having to unclench and relax my fingers more and more often. But while it’s easy to see the drawbacks of the Outsider approach, I have to more and more force myself to step back and reconsider. If the Experts truly have all the knowledge that’s necessary to fix the system, then why isn’t it fixed? Why isn’t it even improving?

No Country for Experts

If we want change, we have to embrace the Outsider, because the “Expert” (or rather, a particular manifestation of expertise) view here is ultimately a trap. When all you see are webs of causation and all of the reasons why the current state exists and why alternatives are not feasible, you are immobilized. The “Expert” approach ultimately leads us back to the current system. We need challenging questions to be asked, premises to be exposed, and structures to be placed in competitive pressures or eliminated. Expertise in the current state won’t save us—at least not alone.

There are these two wolves inside each of us in healthcare. The jaded Expert wolf can see the tar pits and dead ends and understands more of the context and the reasons underlying what is. The Outsider wolf either doesn’t know about or has the courage to disregard these limitations, and has enough audacity to reject the current state and the reasons for its persistence. I think that a challenge for people as they grow in their understanding is to keep the Outsider wolf’s spirit alive, and to harness both expertise and audacity. It certainly has been for me, at least. As 2024 winds down and 2025 looms, I’ll be feeding the Outsider wolf as much as I can.